Managing Care, Not Dollars: The Continuum of Mental Health Services

This book is valuable for anyone involved in mental health and substance abuse treatment, whether clinician, administrator, or purchaser of services. The first section begins with patient vignettes describing cases and the best locale for treatment. Experts, who actually run state-of the-art programs, describe various sites—office-based, home-based, emergency crisis, community residential, partial hospital, hospital-based alcohol and drug, and acute inpatient settings—and outline the treatment.

These private-sector programs, particularly in the section on home care, contain some new twists. They are well worth reading about, even for those who have experience in the public sector, where flexible alternatives to inpatient care are commonplace.

The next section describes specialized treatment alternatives for both the young and the elderly. The focus in each chapter is clinical effectiveness. Alan Axelson's chapter on alternative services for children and adolescents is particularly thoughtful and sets the stage for the more controversial third section of the book.

This third section features chapters by various leaders of managed care organizations arguing for clinical accountability, computer information systems, and outcomes management. Payers will supposedly fund mental health services more adequately when standardization and proven effectiveness characterize the field. A continuum of services makes sense to payers and justifies the role of case managers, which accounts for 30 percent of total expenditures, to oversee the selection of appropriate treatment alternatives. There is no mention of the fact that to date managed behavioral health organizations, by underbidding one another for carve-out business, have cut total expenditures for mental health and substance abuse treatment to historic lows.

My favorite chapter describes the restructuring of Sheppard Pratt from a traditional, nonprofit, private psychiatric hospital into a continuum of mental health and substance abuse services. The inpatient census has dropped dramatically, the average stay has fallen to days instead of months, and yet the hospital survives financially. More patients are being cared for, quickly, but, so far, without compromising the quality of care.

The key is the availability of a spectrum of clinical alternatives to long-term inpatient care. Particularly informative is the table of relative-value units to compensate psychiatrists and psychologists more explicitly and fairly for the new menu of treatment services and venues. It was obviously not easy to roll the dice in 1992 and radically restructure a 100-year-old famous and successful institution to meet the demands of the new managed care world.

One final thought: the book's title, Managing Care, Not Dollars, is misleading. This book is as much about dollars as about managing care. The issues are inseparable. What our field learned from the community mental health movement and from the precipitous closure of many state hospitals is that overly ambitious promises and inadequate funding will undo even well-designed, comprehensive care systems.

Because there is no alternative, we will follow the book. We will set up the continuum of services, work in multidisciplinary teams, buy the computers, evaluate the treatment outcomes, and await the verdict.

Dr. Pomerantz is in private practice in Longmeadow, Massachusetts, and is a lecturer on psychiatry at Harvard Medical School.